Nurse practitioner Violet Rice works with patients in a 10-foot by 11-foot combination office and exam room at the Eklutna Village Clinic. Wednesday, Nov. 27, 2013.

Bill Roth

Violet Rice, a nurse practitioner, administers health care services in a crowded 10-foot by 12-foot clinic in a trailer in Eklutna, the Native village inside Anchorage's borders.

There's no running water. Patients walk next door or to the outhouse to give urine samples. Rice keeps Clorox wipes and hand sanitizer in stock.

"What I found is that there's great need here and there's just not enough money to go around," Rice said.

Questions about funding for the Alaska Tribal Health System came up during Gov. Sean Parnell's drawn-out decision about whether to expand Medicaid under the Affordable Care Act.

Alaska Native-health officials say their health care facilities, like the one in Eklutna, are chronically underfunded. Federal dollars from the Indian Health Service only cover between 40 to 50 percent of the funding needed to provide health care services to the Native population, according to Andy Teuber, chairman of the Alaska Native Tribal Health Consortium, a nonprofit health organization that provides statewide medical services.

So when the Medicaid issue came up, the Alaska Native Tribal Health Consortium lobbied hard to convince Parnell to expand the health insurance program, even commissioning two studies on how it would affect the state.

The governor, upon rejecting Medicaid expansion, echoed a view expressed by many Alaskans over the past year -- that the federal government covers the health needs of all Native Americans, including those in Alaska. When he announced his decision, he subtracted the 17,500 Native people who would've been newly eligible for Medicaid from the total number of uninsured Alaskans at issue -- 43,000. These numbers are from the state-commissioned Lewin Group study.

"About 17,500 of those are eligible for tribal health-organization benefits," he said in a November statement. "So Medicaid expansion could directly benefit about 26,000 of those people."

Teuber said that's not so. There are backlogs of Native people who need to travel for health care, but there's not enough funding. People need wheelchairs, hearing aids and glasses and they have no insurance to cover those expenses. Federal dollars from the Indian Health Service don't explicitly fund them.

"The statement that the governor made during his rejection speech was inaccurate," Teuber said. "Alaskans don't have full access to the health care that they need, and if they did, this wouldn't be such an important issue to the consortium and all the health care facilities across the state."

HEALTH CARE PAST

Some call health care for Alaska Natives and American Indians "prepaid" instead of free. That's because in a series of treaties between Lower 48 tribes and the U.S. government, Native people ceded land and resources in exchange for government protection, including health care. The federal government is considered contractually obligated to provide that service.

Each year, Congress appropriates funding to the Indian Health Service. The money is spread among 1.9 million American Indians and Alaska Natives in the country.

In Alaska, Native health care is administered under the Alaska Tribal Health Compact that authorizes Alaska Native health organizations to provide health care instead of the U.S. government. The compact is signed by 25 tribes and tribal organizations, including the consortium, and serves 229 federally recognized tribes across the state.

For 2014, compact groups received about $606 million in federal funding, Teuber said.

The system serves more than 143,000 Alaska Natives and American Indians. There's a statewide hospital in Anchorage, 25 subregional clinics, six regional hospitals, nearly 200 village clinics, including the one in Eklutna, and five residential substance abuse treatment centers.

"It's a good contribution to the fixed-cost operations," Teuber said. "But it certainly doesn't cover all of the operations."

MEDICAID PAYMENT

But Sharon Leighow, Parnell's spokeswoman, said that when it comes to health care payments, the state shouldn't be expected to pick up where federal dollars fall short.

"The inadequate rate of reimbursement by the Indian Health Service to Alaska's tribal health system is another example of a broken promise by the federal government," Leighow said in an email. "The State of Alaska should not be expected to backfill this expense."

In Parnell's rejection statement, he said Medicaid was already one of the state's most expensive programs, with an annual cost of $1.5 billion and about 140,000 Alaskans enrolled.

Under the Affordable Care Act, the federal government would pay 100 percent of the cost of increasing Medicaid coverage for those whose incomes fall below 138 percent of the poverty level and for expanding coverage to single adults and couples without children. By 2020, the federal share would drop to 90 percent.

Nearly 40 percent of Medicaid recipients are Alaska Natives, according to the state Department of Health and Social Services. Alaska Natives make up 20 percent of the state's total population.

'THIRD-WORLD CONDITIONS'

About 80 percent of Alaska Native villages aren't linked by a road system, according to the Indian Health Service. About 20 percent of rural villages don't have adequate sanitation services, Teuber said.

Lack of running water or indoor plumbing like in Eklutna isn't an anomaly.

"It's objectionable by any standards," Teuber said. "It's third-world conditions, and here we are in the state of Alaska with its vast resources and we look at small village communities that lack the basic infrastructure that we take advantage of."

Among many village clinics, the highest level medical professional is a health aide, comparable in training to a paramedic, said Donna Bach, a spokeswoman for the Yukon-Kuskokwim Health Corp.

The health care organization, about 400 air miles from Anchorage, services 58 tribes in an area roughly the size of Oregon where roads don't connect neighboring communities.

"If there's anything beyond (health aides') expertise, or for patients that have chronic issues, we have to coordinate or schedule to send those individuals to Bethel or onto higher levels of care, to Anchorage or Seattle," Bach said. "That's where the Medicaid provision comes in handy because it would help handle lodging."

Medicaid covers medically necessary travel, but Indian Health Service funding typically only covers "urgent" travel -- when a patient is at risk of the "loss of life or limb," Teuber said.

It would take an "extreme emergency" before an 18-year-old Alaska Native in a rural village with a toothache and no health insurance was referred to Bethel for treatment, Bach said.

"We simply lack the transportation funds to accommodate everybody at a time of need," Teuber said. "So it creates a little bit of a backlog. Often in cases, we're not immediately able to treat someone with immediate needs."

Even Rice in Eklutna said some of her patients don't have the means or the money to make it to the clinic. So she packs a bag and goes to them whether in Anchorage or Palmer.

"Anything extra helps us to give more care," Rice said about funding. "It's not like we're going out on Wall Street to buy big stock with the money they're giving us. We're buying Band Aids and dressing and antibiotics."